Figure TAC c Long Term Care Insurance Claim Denials Reporting

							Figure: 28 TAC §3.3837(c)(2)


                                    Long-Term Care Insurance
                                   Claim Denials Reporting Form

                                      FOR THE STATE OF TEXAS

                              For the Reporting Year of _____________

                Due: No later than June 30 annually for the preceding calendar year

Company Name: _______________________________________________________
Company Address: _____________________________________________________
_____________________________________________________________________
Company NAIC Number: ________________________________________________
Contact Person: _______________________ Phone Number: __________________

Line of Business:                Individual              Group

Instructions

The purpose of this form is to report all long-term care claim denials under in force long-term care
insurance policies. "Claim" means a request for payment of benefits under an in-force policy regardless of
whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been
met.

Indicate the manner of reporting by checking one of the boxes below.

    Per Claimant - counts each individual who makes one or a series of claim requests

    Per Transaction - counts each claim request

"Denied" means a claim that is not paid for any reason other than for failure to meet the waiting period or
because of an applicable preexisting condition. It does not include a request for payment that is in excess
of the applicable contractual limits.

                                                                                 State       Nationwide
                                                                                 Data        Data1
1     Total Number of Long-Term Care Claims Reported
2     Total Number of Long-Term Care Claims Denied/Not Paid
3     Number of Claims Not Paid due to Preexisting Condition
      Exclusion
4     Number of Claims Not Paid due to Waiting (Elimination) Period
      Not Met
5     Net Number of Long-Term Care Claims Denied for Reporting
      Purposes (Line 2 Minus Line 3 Minus Line 4)
6     Percentage of Long-Term Care Claims Denied of Those Reported
      (Line 5 divided by Line 1)
 7   Number of Long-Term Care Claims Denied due to:
 8     • Long-Term Care Services Not Covered under the Policy2
 9     • Provider/Facility Not Qualified under the Policy3
10     • Benefit eligibility Criteria Not Met4
11     • Other5

1.     The nationwide data may be viewed as a more representative and credible indicator where the
       data for claims reported and denied for your state are small in number.
2.     Example: home health care claim filed under a nursing home only policy.
3.     Example: a facility that does not meet the minimum level of care requirements or the licensing
       requirements as outlined in the policy.
4.     Examples: (i) a benefit trigger not met; (ii) certification by a licensed health care practitioner not
       provided; (iii) no plan of care.
5.     Examples: duplicate submission, incomplete claim submission, advance billing.

Form Number LHL564(LTC)